Brookland-Lakeview COLA Afterschool Program

21st Century Community Learning Center (21st CCLC)

2022-2023 TRANSPORTATION INFORMATION SHEET

BROOKLAND-LAKEVIEW COLA AFTERSCHOOL PROGRAM

Student's First Name *

Student's Last Name *

Drop-Off Address *

Person at drop-off location *

Cell # of person at of drop-off location

Home telephone of drop-off location

Are there any special directions for this drop-off address?

Authorized persons to pick up your student from the Afterschool Program *

Parent/Guardian Name *

Street Address (No PO Box #) *

I understand that my child must attend regularly, exhibit acceptable behavior, and be picked up promptly at dismissal time if she/he is a car rider.

I acknowledge that all the information given is correct to the best of my knowledge. I am the parent/guardian and have legal custody of the child being enrolled.

Parent Name *

Date *

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